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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803785
Report Date: 04/28/2023
Date Signed: 04/29/2023 04:15:36 PM

Document Has Been Signed on 04/29/2023 04:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MELROSE HOMEFACILITY NUMBER:
197803785
ADMINISTRATOR:DELIA COLLANTESFACILITY TYPE:
735
ADDRESS:4174 CENTER ST.TELEPHONE:
(626) 813-7525
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 6CENSUS: 6DATE:
04/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Staff 1TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an announced Case Management visit regarding Special Incident Report (SIR) dated 04-17-2023. LPA was met by Staff 1 (S1) and explained the purpose of the visit. Administrator Delia Collantes was notified via phone of visit by LPA. LPA and S1 toured facility. LPA requested and obtained copies of Personnel Report (LIC 500), Resident Roster, Client 1 (C1) Face Sheet, C1’s Individual Program Plan (IPP), and other pertinent documents regarding this investigation.

On 04-26-23, LPA Ramirez received a Special Incident Report (SIR) dated 04-17-23 from Administrator Collantes regarding C1. SIR indicates at 5 a.m., S1 noticed a bruise on C1 right upper arm. C1 was later taken to see primary care physician on 04-17-23. On 04-18-23, C1 was taken for an x-ray exam, and it was determined C1 suffered from minimally displaced fracture of the right greater tuberosity.

LPA toured facility and interviewed three staff, attempted interview of four clients and, one client interview. LPA toured C1’s shared bedroom. C1 is the only client occupying this room currently. LPA observed two twin size beds, 2 folding chairs, two nightstands, one dresser, and TV. It is unknown at this time how C1 suffered injury. When LPA questioned C1 on how C1 injured their arm, C1 responded “I fall”. Staff interviewed deny hearing or witnessing C1 fall. According to staff interviewed, C1 did not report fall on 04-17-23 or that C1 was in pain. Due to cognitive issues, LPA interview of C1 was limited. LPA did not observe any hazards, health and safety violations or Title 22 deficiencies.

Licensee/Administrator will continue to monitor C1’s recovery and possibly reassess C1 needs and services. Licensee/Administrator will work with San Gabriel/Pomona Regional Center and discuss possible fall assessment for C1.

Exit interview was held with S1 and a copy of this report was emailed to Administrator Collantes.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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